Stroke - A Complete Guide for Physiotherapists

1. DEFINITION

2. TYPES OF STROKE

Ischemic Stroke Subtypes (TOAST Classification)

1. Large artery atherosclerosis - carotid/vertebral plaque rupture + thrombosis
2. Cardioembolism - clot from heart (atrial fibrillation is the most common cause)
3. Small vessel / Lacunar - penetrating artery disease; causes pure motor or sensory strokes
4. Cryptogenic - no identified cause
5. Other determined cause - vasculitis, dissection, coagulopathy

Three major mechanisms: (1) cardiogenic embolism from AF/valve disease, (2) artery-to-artery embolism from carotid plaque, (3) in-situ thrombosis of small penetrating arteries - Harrison's 22E

3. PATHOPHYSIOLOGY

Ischemic Cascade

• CBF < 16-18 mL/100g/min → neuronal dysfunction (recoverable with reperfusion)
• CBF → 0 → brain tissue death within 4-10 minutes

The ischemia cascade: occlusion → energy failure → glutamate release → Ca²+/Na+ influx → proteolysis → cell death. NOS = inducible nitric oxide synthase; PARP = poly ADP-ribose polymerase - Harrison's 22E

4. RISK FACTORS

• Hypertension (single biggest risk factor)
• Atrial fibrillation
• Diabetes mellitus
• Dyslipidemia
• Smoking
• Physical inactivity - PT role in secondary prevention
• Obesity
• Carotid artery stenosis

5. CLINICAL FEATURES BY VASCULAR TERRITORY

Middle Cerebral Artery (MCA) - Most Common

• Contralateral hemiplegia - upper limb > lower limb (face and arm worse than leg)
• Contralateral hemisensory loss
• Homonymous hemianopia (visual field defect)
• If dominant (usually left) hemisphere: aphasia (Broca's = expressive; Wernicke's = receptive)
• If non-dominant hemisphere: neglect, anosognosia (unawareness of paralysis), constructional apraxia

Anterior Cerebral Artery (ACA)

• Contralateral leg > arm weakness (foot/leg more affected than hand/face)
• Contralateral leg sensory loss
• Urinary incontinence
• Grasp and suck reflexes, abulia (lack of motivation)

Posterior Cerebral Artery (PCA)

• Homonymous hemianopia (pure or with macular sparing)
• Memory impairment
• Thalamic sensory loss
• Less motor involvement than MCA

Brainstem Stroke (Vertebrobasilar)

• Crossed deficits (ipsilateral face + contralateral body) - hallmark
• Lateral Medullary (Wallenberg's) syndrome: dysphagia, ipsilateral Horner's, ataxia, contralateral pain/temperature loss
• Dysarthria, dysphagia, diplopia, vertigo, ataxia
• Locked-in syndrome (basilar artery): conscious but unable to move except eye movements

Lacunar Infarcts (Small Vessel)

• Pure motor hemiparesis (posterior limb of internal capsule or pons)
• Pure sensory stroke (thalamus)
• Ataxic hemiparesis (ipsilateral ataxia + contralateral weakness)
• Dysarthria-clumsy hand syndrome
• Generally better prognosis

Cerebellar Stroke

• Ipsilateral ataxia, dysmetria, dysdiadochokinesia
• Vertigo, nausea, nystagmus
• No hemiplegia unless brainstem compressed
• Risk of fatal herniation into foramen magnum - monitor closely

6. NEUROLOGICAL DEFICITS - THE PT ASSESSMENT FRAMEWORK

Motor Deficits (Most Relevant to PT)

• Hypotonia, absent or decreased reflexes
• Limb is limp; arm hangs, leg buckles
• Risk of shoulder subluxation, contracture, DVT

• Spasticity develops gradually
• Upper limb pattern: shoulder adduction + internal rotation, elbow flexion, wrist/finger flexion
• Lower limb pattern: hip extension + adduction, knee extension, ankle plantar flexion + inversion (equinovarus) - the "hemiplegic gait" posture
• Tendon reflexes become brisk, Babinski sign positive
• Botulinum toxin can help relieve focal spasticity

Sensory Deficits

• Hemisensory loss (contralateral to lesion)
• Deep sensory loss (proprioception, vibration) is a major limiting factor for gait and balance rehabilitation
• Pain sensation loss increases risk of pressure sores and burns

Cognitive and Perceptual Deficits

• Neglect (unilateral spatial neglect) - patient ignores affected side - significantly impairs rehabilitation
• Apraxia - inability to perform learned movements despite intact motor and sensory function; movement doesn't "make sense" to patient
• Anosognosia - unawareness of the paralysis; patient may resist therapy
• Attention and concentration deficits
• Memory impairment
• Vascular dementia - multiple infarcts over time lead to cumulative cognitive decline

Communication Deficits

• Aphasia - affects verbal communication; coordinate with speech therapist; use written/picture communication if needed
• Dysarthria - slurred speech but language intact; patient understands commands

Other PT-Relevant Deficits

• Dysphagia - aspiration risk; inform team; sit patient upright for exercises
• Hemianopia - visual field loss; patient may not see on affected side; safety during ambulation
• Bladder/bowel incontinence - usually resolves; manage with pads initially
• Depression and emotional lability - common after left frontal lesions and others; impacts motivation and rehab participation
• Fatigue - very common; patients tire quickly; plan session duration accordingly
• Post-stroke pain - central pain (thalamic), shoulder pain, spasticity pain

7. PROGNOSIS FOR RECOVERY - WHAT TO TELL PATIENTS

• If clinical recovery does not begin in 1-2 weeks, outlook is poorer for both motor and language functions
• Motor and language deficits remaining after 5-6 months are likely to be permanent
• However: aphasia, dysarthria, cerebellar ataxia, and walking may improve for a year or longer
• Nearly all hemiplegic patients regain the ability to walk to some extent, usually within 3-6 months - this should be the primary PT aim
• Key limiting factors for ambulation: deep sensory loss + anosognosia (in addition to hemiplegia)
• Lacunar infarct patients generally fare well but may take months to reach maximum improvement
• Constructional apraxia, neglect, hemianopia - tend to diminish over weeks but hemianopia that hasn't cleared in weeks is usually permanent

8. PHYSIOTHERAPY MANAGEMENT - BY PHASE

Phase 1: Acute (ICU/Acute Ward, Day 1 onwards)

• Prevent complications of immobility
• Preserve joint range of motion
• Maintain skin integrity
• Begin early mobilization

• Passive range of motion (PROM): Carry paralyzed limbs through full ROM several times daily - prevents contracture (capsulitis), especially at shoulder, elbow, hip, knee, and ankle
• Positioning: Correct anti-spasticity positioning in bed and chair; protect shoulder from subluxation
• Early mobilization: Move patient from bed to chair as soon as BP is stable
• DVT prophylaxis: Compression boots + active exercise when possible
• Swallowing assessment - critical before oral intake; PT assists with positioning (upright) to reduce aspiration risk
• Respiratory physiotherapy if needed (pneumonia prevention)
• Avoid immobilizing splints - studies have shown undesirable effects of prolonged splinting after stroke

• Shoulder pain / capsulitis - begin early shoulder PROM; avoid traction on flaccid shoulder
• DVT - calf squeeze, early mobilization
• Pressure sores - positioning, regular turning
• Aspiration pneumonia - positioning, oral hygiene, swallow screening

Phase 2: Subacute Rehabilitation (Inpatient Rehab, Weeks to Months)

• Maximize motor recovery and neuroplasticity
• Achieve independent ambulation
• Independence in ADLs
• Manage spasticity

Neuroplasticity Principles Underlying All PT:

1. Task-Specific Training

• Practice actual functional tasks repeatedly (walking, reaching, transfers)
• Intensity matters - more therapy = better outcomes: adding just 30 min/day of focused treatment to leg or arm (5 days/week for 20 weeks) achieves significantly better walking ability and dexterity - Adams & Victor, Kwakkel RCT

2. Gait Retraining

• Progressive gait training - parallel bars → walker → cane → independent
• Ankle-Foot Orthosis (AFO): Use early to assist foot clearance and knee control. Improves weight-bearing on affected leg, increases single-limb stance time, reduces postural sway. Indicated for:
  • Inadequate dorsiflexion for heel contact or toe clearance
  • Excessive hip hiking during swing
  • Mediolateral subtalar instability
  • Tibial instability during stance
• AFO set in slight plantarflexion if knee buckles (extends knee earlier); 5° dorsiflexion decreases knee hyperextension
• Treadmill training with body weight support - allows earlier gait practice
• Balance training - dynamic balance, reactive balance, perturbation training

3. Constraint-Induced Movement Therapy (CIMT)

• Immobilize the unaffected upper limb (mitt on good hand) and force use of hemiplegic limb >90% of waking time for 2 weeks
• Reflects cortical motor representation expansion into adjacent undamaged areas
• Benefits shown even years after stroke - Wolf RCT, Adams & Victor
• Current Cochrane review (2025) confirms physical rehabilitation improves function and mobility

4. Strength Training

• Resistance training is safe and effective post-stroke
• Recent meta-analysis (BJSM 2025) confirms strength training improves muscle strength, function, and quality of life
• Progressive resistance exercises for upper and lower limbs

5. Mirror Therapy

• Patient views mirror image of moving unaffected limb creating illusion of moving paretic side
• Cochrane meta-analysis of 14 studies: modest benefit in motor recovery + more prominent benefit for pain relief and quality of life - Adams & Victor

6. Balance and Proprioception Training

• Standing balance exercises
• Perturbation training
• Core stability
• Visual feedback training (mirror, video)
• Particularly important when deep sensory loss is present

7. Spasticity Management

• Prolonged stretching - daily passive stretching of spastic muscles
• Positioning - anti-spasticity positioning (shoulder abduction, elbow extension, wrist/fingers extension; ankle in neutral)
• Splinting - static night splints at wrist/ankle to maintain length
• Functional electrical stimulation (FES) - reduces spasticity, improves voluntary activation
• Cryotherapy - temporary reduction in spasticity
• Coordination with medical team for botulinum toxin injections when splinting insufficient

8. Sensory Retraining

• Graded tactile stimulation
• Proprioceptive exercises
• Mirror therapy for sensory as well as motor deficits
• Attention to safety for patients with deep sensory loss

9. Dysphagia (if trained in oro-motor rehab)

• Positioning strategies (upright sitting, chin tuck)
• Oral motor exercises
• Recent meta-analysis (2023) supports transcranial direct current stimulation for post-stroke dysphagia

10. Virtual Reality (VR) Rehabilitation

• Recent Cochrane review (June 2025) shows VR improves upper limb function and activity compared to conventional therapy or as a dose-matched supplement
• Engaging, repetitive, task-specific - promotes neuroplasticity
• Increasingly available as affordable technology

Phase 3: Community/Home Rehabilitation

• Maintain and build on gains
• Prevent secondary complications (falls, re-stroke, deconditioning)
• Maximize participation in home/community
• Home exercise programs - self-management skills
• Falls prevention - home environment assessment, balance training, footwear
• Aerobic exercise - walking programs, cycling; beneficial for cardiovascular risk (secondary stroke prevention)
• Home-based exercise for post-stroke depression - systematic review (2024) confirms home exercise reduces post-stroke depression
• Caregiver training in handling, transfers, passive exercises
• Community ambulation training

9. OUTCOME MEASURES USED IN STROKE PT

10. SHOULDER PAIN - A KEY PT CONCERN

• Subluxation - from hypotonic deltoid pulling humeral head inferiorly
• Capsulitis / frozen shoulder - from immobility; begins early if PROM not started
• Shoulder-hand syndrome (Complex Regional Pain Syndrome Type 1) - pain, atrophy of bone in hand accompanying shoulder pain
• Rotator cuff tear - from improper handling or falls

• Correct positioning and support of flaccid shoulder from day 1
• Avoid traction (pulling on the arm during transfers)
• Begin shoulder PROM within days of stroke
• Arm slings in standing/ambulation when shoulder is subluxed and flaccid

11. STROKE UNIT & MULTIDISCIPLINARY TEAM

12. SECONDARY PREVENTION - PT'S ROLE

• Physical activity counseling - regular aerobic exercise reduces BP, glucose, lipids
• Exercise prescription for cardiovascular fitness
• Weight management guidance
• Falls prevention strategies
• Encourage smoking cessation, medication adherence (education)

13. NEUROPLASTICITY - THE SCIENCE BEHIND YOUR WORK

1. Use it or lose it - neurons that don't fire together lose their connections
2. Use it and improve it - training drives specific brain changes
3. Specificity - the training must be task-specific to the goal
4. Repetition matters - thousands of repetitions are needed for plastic change
5. Intensity matters - more therapy time = better outcomes
6. Time matters - earlier is better; there is a critical window but recovery continues for years
7. Salience - meaningful, engaging tasks drive greater plasticity
8. Transference - skills gained in one context transfer to others (limited)

14. RED FLAGS DURING REHABILITATION

• Sudden worsening of neurological deficits (stroke extension or new stroke)
• Severe headache, vomiting, decreased consciousness (hemorrhagic transformation)
• BP > 220/120 mmHg (ischemic) or significant hypo/hypertension
• Signs of DVT (unilateral calf swelling, pain, warmth)
• Aspiration during oral feeding (coughing, desaturation, wet voice)
• Chest pain, arrhythmia, significant desaturation during exercise
• Signs of seizure activity

• Harrison's Principles of Internal Medicine, 22nd Ed. (McGraw Hill, 2025) - Chaps 437/438
• Adams and Victor's Principles of Neurology, 12th Ed.
• Bradley and Daroff's Neurology in Clinical Practice
• Cochrane Review: Physical rehabilitation approaches for stroke recovery (2025) - PMID 39932103
• Prescribing strength training for stroke recovery (BJSM 2025) - PMID 39406459
• Virtual reality for stroke rehabilitation, Cochrane 2025 - PMID 40537150
• Home-based exercise for post-stroke depression (2024) - PMID 38290424